Volume C: Addiction Medications and Special Populations Volume
C: Addiction Medications and Special Populations Treatnet Training
Volume C: Module 1 Updated 19 February 2008 Slide 2 Volume C:
Addiction Medications and Special Populations Module 1: Addiction
Basics: Alcohol and Benzodiazepines; Psychostimulants, Volatile
Substances, and Cannabis Workshop 1 Workshop 2 Workshop 3 Module 2:
Opioids: Basics of Addiction; Opiate Agonist, Partial Agonist, and
Antagonist Therapies Workshop 1Workshop 2Workshop 3 Module 3:
Special Populations: Individuals with Co-Occurring Disorders,
Women, and Young People Workshop 1Workshop 2Workshop 3 Workshop 4
Slide 3 Module 1: Addiction Basics: Alcohol and Benzodiazepines;
Psychostimulants; Volatile Substances and Cannabis Slide 4 Module
1: Training goals 1.Increase knowledge of the medical and
addiction-related problems associated with alcohol,
benzodiazepines, psychostimulants, volatile substances and
cannabis. 2.Learn the appropriate medical detoxification and post
detoxification pharmacotherapies appropriate to treat these
substance use disorders. 3.Promote the use of these techniques by
practionners and organizations Slide 5 Module 1: Workshops Workshop
1: Addiction Basics Workshop 2: Alcohol & Benzodiazepines;
Medical Issues, Detoxification Approaches Workshop 3:
Psychostimulants, Volatile Substances and Cannabis Slide 6
Icebreaker: Drugs in my country What is the main consumed drug in
your country? What is the main consumed drug in your country? What
are the main problems that this drug is creating among people in
your country? What are the main problems that this drug is creating
among people in your country? 15 Min. Slide 7 Workshop 1: Drug
Abuse and Addiction Source: NIDA (www.projectcork.org) Slide 8
Pre-assessment Please respond to the pre-assessment questions in
your workbook. (Your responses are strictly confidential.) (Your
responses are strictly confidential.) 10 Min. Slide 9 Training
Objectives At the end of this training you will be able to:
1.Understand basic principles and concepts of drug abuse and
dependence. 2.Understand the basic pharmacology of alcohol,
benzodiazepines, psychostimulants, volatile substances and cannabis
3.Understand the specific role of pharmacotherapy for overdose,
withdrawal treatments, maintenance treatments and relapse
prevention treatments. 4.Understand clinical populations and
treatment settings where pharmacotherapies can be used. Slide 10
Why do people initiate drug use? Key Motivators Fun (pleasure) Fun
(pleasure) Forget (pain amelioration) Forget (pain amelioration)
Functional (purposeful) Functional (purposeful) (NCETA, 2004)
(NCETA, 2004) Also initiation starts through: Experimental use
Experimental use Peer pressure Peer pressure Slide 11 1.Risk-takers
/ pleasure seekers 2.Socially disconnected 3.Self-medicators
Understanding young peoples motivation to use drugs Slide 12 Types
of drug users Enormous variability and range include: Experimenters
Experimenters Social users Social users Regular heavy users Regular
heavy users Dependent users Dependent users Slide 13 dependent
intensive purposive experimental Patterns of drug use Slide 14
Factors that influence drug use There are at least three different
categories of factors to consider: predisposing factors
predisposing factors precipitating (enabling) factors precipitating
(enabling) factors perpetuating (reinforcing) or maintaining
factors perpetuating (reinforcing) or maintaining factors Slide 15
Drugs and genes While psychological theories account for a large
proportion of the behaviours related to drug use, other factors are
also important While psychological theories account for a large
proportion of the behaviours related to drug use, other factors are
also important It is increasingly recognised that genes play an
important role in an individuals response to drugs and the
propensity for the development of dependence It is increasingly
recognised that genes play an important role in an individuals
response to drugs and the propensity for the development of
dependence Slide 16 Environmental factors A range of environmental
factors impact on drug use, including price and availability of
both licit and illicit drugs A range of environmental factors
impact on drug use, including price and availability of both licit
and illicit drugs Other environmental factors include prenatal
problems, early childhood experiences, family relationship and
bonding, and early educational opportunities. Other environmental
factors include prenatal problems, early childhood experiences,
family relationship and bonding, and early educational
opportunities. Cultural norms around drug use also act as powerful
determinants of the use of both licit and illicit substances
Cultural norms around drug use also act as powerful determinants of
the use of both licit and illicit substances Slide 17 Psychoactive
drugs are generally defined as substances that alter: mood mood
cognition (thoughts) cognition (thoughts) behaviour behaviour
Psychoactive drugs (1) Slide 18 Psychoactive drugs (2) Affect
mental processes and behaviour Affect mental processes and
behaviour Affect thought processes and actions Affect thought
processes and actions Alter perceptions of reality Alter
perceptions of reality Change level of alertness, response time,
and perception of the world Change level of alertness, response
time, and perception of the world Achieve effects by interacting
with the central nervous system (CNS) Achieve effects by
interacting with the central nervous system (CNS) Carmichael (2001)
Slide 19 Psychoactive drug use Is a common activity Is a common
activity Is part of a range of human behaviours Is part of a range
of human behaviours Can be classified in many ways, including legal
status, drug effects Can be classified in many ways, including
legal status, drug effects Alters mood or consciousness, although
there are other ways to achieve this: Alters mood or consciousness,
although there are other ways to achieve this: e.g., skydiving,
meditation, extreme (and non- extreme) sports, sex. Children, for
example, love to alter their consciousness by spinning around.
e.g., skydiving, meditation, extreme (and non- extreme) sports,
sex. Children, for example, love to alter their consciousness by
spinning around. Slide 20 Views about AOD-related issues experience
experience culture culture education education religion religion
Our thinking about alcohol and other drug (AOD) related issues is
informed by factors such as: family / environment legislation Slide
21 Psychoactive drugs may be classified according to their: 1.
Status legal legal chemical chemical medical medical social social
2. Action and properties depressant stimulant hallucinogenic etc.
Drug classifications Slide 22 Classifying psychoactive drugs
DepressantsStimulantsHallucinogens AlcoholAmphetamines LSD, DMT
BenzodiazepinesMethamphetamineMescaline OpioidsCocainePCP
SolventsNicotineKetamine BarbituratesKhat Cannabis (high doses)
Cannabis (low doses) Caffeine Magic mushrooms MDMAMDMA Slide 23
Drug use and health Patients with drug problems: often have
multiple health and social problems often have multiple health and
social problems expect doctors to ask and provide information about
alcohol and drug issues failure to inquire may lead to medical
malpractice in some situations expect doctors to ask and provide
information about alcohol and drug issues failure to inquire may
lead to medical malpractice in some situations Slide 24 Types of
problems (1) Different patterns of drug use result in different
types of problems Different patterns of drug use result in
different types of problems Because individuals have different
genetic make ups and early experiences, they may respond
differently to drugs and have a different risk for drug abuse and
dependence Because individuals have different genetic make ups and
early experiences, they may respond differently to drugs and have a
different risk for drug abuse and dependence Drug use may affect
all areas of a patients life, and problems are not restricted to
dependent drug use Drug use may affect all areas of a patients
life, and problems are not restricted to dependent drug use Slide
25 Types of problems: Thorleys Model Intoxication Accidents /
injury Poisoning / hangovers Absenteeism High-risk behaviour
Regular / excessive Use Health Finances Relationships Child neglect
Dependence Impaired control Drug-centred behaviour Isolation /
social problems Withdrawal symptoms and psychiatric problems Health
Problems I R D Slide 26 Drug Route, effects, actions, purity,
potency, quality Form, price, availability, interaction with other
drugs, previous experience Physical / emotional reaction, mood,
current health, age, tolerance, knowledge, beliefs, memories,
expectations Individual Where, when, who, how, employment, social
context, supply, peers, legality, culture, media, advertising,
availability Interactive Model of Drug Use The Drug Use Experience
Environment Slide 27 Important terminology 1.Harmful use 2.Physical
dependence vs. addiction 3.Psychological craving 4.Tolerance
5.Withdrawal symptoms 6.Neurotransmitters and receptors Slide 28
What is harmful use? (ICD-10) A pattern of psychoactive substance
use that is damaging to physical and / or mental health. Slide 29
What is drug addiction? Drug addiction is a complex illness
characterised by compulsive, and at times, uncontrollable drug
craving, seeking, and use that persist even in the face of
extremely negative consequences. (NIDA, 1999) Slide 30
Characteristics of addiction Compulsive behaviour Compulsive
behaviour Behaviour is reinforcing (rewarding or pleasurable)
Behaviour is reinforcing (rewarding or pleasurable) Loss of control
in limiting intake Loss of control in limiting intake (NIDA;
www.projectcork.org) Slide 31 Psychological craving Psychological
craving is a strong desire or urge to use drugs. Cravings are most
apparent during drug withdrawal. Slide 32 Tolerance A state in
which a person no longer responds to a drug as they did before, and
a higher dose is required to achieve the same effect. Slide 33 A
period during which somebody addicted to a drug or other addictive
substance reduces their use or stops taking it, causing the person
to experience painful or uncomfortable symptoms OR A person takes a
similar substance in order to avoid experiencing the effects
described above. Withdrawal (1) Slide 34 Withdrawal (2) When a drug
is removed, physical and / or mental disturbances may occur,
including: Physical symptoms Physical symptoms Emotional problems
Emotional problems Cognitive and attention deficits Cognitive and
attention deficits Aggressive behavior Aggressive behavior
Hallucinations Hallucinations Convulsions Convulsions Death Death
Slide 35 DSM IV criteria for substance dependence Three or more of
the following occurring at any time during the same 12 month
period: Tolerance Tolerance Withdrawal Withdrawal Substance taken
in larger amounts over time Substance taken in larger amounts over
time Persistent desire and unsuccessful efforts to cut down or stop
Persistent desire and unsuccessful efforts to cut down or stop A
lot of time and activities spent trying to get the drug A lot of
time and activities spent trying to get the drug Disturbance in
social, occupational, or recreational functioning Disturbance in
social, occupational, or recreational functioning Continued use in
spite of knowledge of the damage it is doing to the user or others
Continued use in spite of knowledge of the damage it is doing to
the user or others (DSM-IV-TR, American Psychiatric Association,
2000.) Slide 36 ICD-10 criteria for dependence Dependence: 3 or
more of the following: (a) strong desire or sense of compulsion to
take the substance; (b) difficulties in controlling
substance-taking behaviour in terms of its onset, termination, or
levels of use; (c) a physiological withdrawal state; (d) evidence
of tolerance; (e) progressive neglect of alternative pleasures or
interests (f) persisting with substance use despite clear evidence
of overtly harmful consequences Slide 37 In this training,
addiction will be the term used to refer to the pattern of
continued use of drugs despite pathological behaviours and other
negative outcomes In this training, addiction will be the term used
to refer to the pattern of continued use of drugs despite
pathological behaviours and other negative outcomes Dependence will
only be used to refer to physical dependence on the substance as
indicated by tolerance and withdrawal as described above Dependence
will only be used to refer to physical dependence on the substance
as indicated by tolerance and withdrawal as described above To
avoid confusion Slide 38 Addiction = Brain Disease Addiction is a
brain disease that is chronic and relapsing in nature. (NIDA;
www.projectcork.org) Slide 39 A major reason people take a drug is
they like what it does to their brains A major reason people take a
drug is they like what it does to their brains Slide 40 How the
reward system works Slide 41 Slide 42 0 0 50 100 150 200 0 0 60 120
180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding
Source: Di Chiara et al. FOOD Natural rewards elevate dopamine
levels Slide 43 Activating the system with drugs (NIDA;
www.projectcork.org) Slide 44 0 0 100 200 300 400 Time After
Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 0 0 100
150 200 250 0 0 1 1 2 2 3 hr Time After Nicotine % of Basal Release
Accumbens Caudate NICOTINE Source: Shoblock and Sullivan; Di Chiara
and Imperato Effects of Drugs on Dopamine Release Time After
Methamphetamine % Basal Release METHAMPHETAMINE 0123hr 1500 1000
500 0 Accumbens Slide 45 Why cant people just stop drug use? When
people first try drugs, it is usually a voluntary decision, but
after using the drug for a while, it is no longer voluntary. Why
cant people stop? Slide 46 Slide 47 Slide 48 Partial Recovery of
Brain Dopamine Transporters in Methamphetamine (METH) Abuser After
Protracted Abstinence Normal Control METH Abuser (1 month detox)
METH Abuser (24 months detox) 0 3 ml/gm (Volkow, N.D., et al. 2001.
Journal of Neuroscience 21, 9414-9418.) Slide 49 Their Brains have
been Re-Wired by Drug Use Their Brains have been Re-Wired by Drug
Use Because Slide 50 Prolonged drug use changes the brain in
fundamental and long-lasting ways! Why cant people just stop drug
use? Slide 51 Compulsive Drug Use (Addiction) Compulsive Drug Use
(Addiction) Voluntary Drug Use Voluntary Drug Use Slide 52 Its Not
Just Addiction is, Fundamentally, A Brain Disease Brain Disease A
Brain Disease A Brain Disease...BUT Slide 53 DRUGS BRAIN MECHANISMS
BEHAVIOR ENVIRONMENT HISTORICAL ENVIRONMENTAL - previous history -
expectation - learning - social interactions - stress - conditioned
stimuli - genetics - circadian rhythms - disease states - gender
PHYSIOLOGICAL Slide 54 Questions?Comments? ? ? ? Slide 55
Post-assessment Please respond to the post-assessment questions in
your workbook. (Your responses are strictly confidential.) 10 Min.
Slide 56 Thank you for your time! End of Workshop 1 Slide 57 Volume
C, Module 1, Workshop 2: Alcohol & Benzodiazepines; Medical
Issues, Detoxification Approaches, Pharmacotherapies Volume C,
Module 1, Workshop 2: Alcohol & Benzodiazepines; Medical
Issues, Detoxification Approaches, Pharmacotherapies Treatnet
Training Volume C: Module 1 Updated 18 October 2007 Slide 58
Training objectives At the end of this training you know: 1.Acute
and chronic effects of alcohol and benzodiazepines, the medical and
psychiatric dangers associated with intoxication, overdose,
withdrawal, and interactions with other substances 2.Treatment
protocols to treat intoxication and overdose 3.Withdrawal
approaches and protocols 4.Necessary treatments following
detoxification 5.Proper setting and support services needed to
properly conduct withdrawal treatments Slide 59 Alcohol Slide 60
Acute alcohol-related harms Physical injury and psychological harms
and death arise from: Falls Falls Physical assaults Physical
assaults Sexual assaults Sexual assaults Domestic violence Domestic
violence Traffic accidents Traffic accidents Occupational &
machinery injuries Occupational & machinery injuries Fires
Fires Drowning Drowning Child abuse Child abuse Unprotected sex
leading to STDs and HIV Unprotected sex leading to STDs and HIV
Overdose Overdose Comorbidity Comorbidity Dehydration Dehydration
Sleep disturbances Sleep disturbances Raised blood pressure Raised
blood pressure Shortness of breath Shortness of breath Slide 61
Alcohol Still the most popular drug Still the most popular drug In
some societies over 80% of population drinks In some societies over
80% of population drinks 8% drink daily, peak in males +60 yrs
(23%). 40% drink weekly. 8% drink daily, peak in males +60 yrs
(23%). 40% drink weekly. At-risk drinking now defined as: At-risk
drinking now defined as: risks of harm in the long term (chronic
harm) risks of harm in the long term (chronic harm) risks of harm
in the short term (acute harm) risks of harm in the short term
(acute harm) Slide 62 A standard drink Slide 63 Risky drinking
levels (for chronic harm) Slide 64 Alcohol-induced memory loss
Teenagers (28.4%) were most likely to have a memory loss incident
following drinking: Teenagers (28.4%) were most likely to have a
memory loss incident following drinking: 4.4% reported blackouts
occurring on weekly basis 4.4% reported blackouts occurring on
weekly basis 10.9% reported blackouts on a monthly basis 10.9%
reported blackouts on a monthly basis Memory loss occurred after
drinking for: Memory loss occurred after drinking for: 12% male
drinkers aged > 40 years 12% male drinkers aged > 40 years 7%
female drinkers aged > 40 years 7% female drinkers aged > 40
years 20% - 30% of all other age groups 20% - 30% of all other age
groups Slide 65 Predisposing factors for high-risk drinking Family
history of alcohol problems Family history of alcohol problems
Childhood problem behaviours related to impulse control Childhood
problem behaviours related to impulse control Poor coping responses
in the face of stressful life events Poor coping responses in the
face of stressful life events Depression, divorce, or separation
Depression, divorce, or separation Drinking partner Drinking
partner Working in a male-dominated environment Working in a
male-dominated environment Slide 66 Concurrent mental health
problems Alcohol may: exacerbate existing mental health problems
exacerbate existing mental health problems interact with prescribed
medications interact with prescribed medications reduce or
exacerbate the effect of certain medications reduce or exacerbate
the effect of certain medications reduce patient compliance with
treatment regimens reduce patient compliance with treatment
regimens Slide 67 Women and alcohol Women are more susceptible to
the effects of alcohol due to: smaller physical size smaller
physical size decreased blood volume decreased blood volume lower
body water to fat ratio lower body water to fat ratio reduced ADH
activity in gastric mucosa (hence reduced stomach metabolism of
alcohol). reduced ADH activity in gastric mucosa (hence reduced
stomach metabolism of alcohol). Resulting in: earlier development
of organ damage earlier development of organ damage increased risk
of intoxication related harms; e.g., assault, injury. increased
risk of intoxication related harms; e.g., assault, injury. Slide 68
Fetal Alcohol Syndrome (FAS) Increasing prevalence of risky
drinking by young women has raised concerns about fetal alcohol
syndrome / effects. Slide 69 FAS Diagnosis 1. Prenatal or postnatal
growth retardation 2. Brain dysfunction (intellectual retardation,
poor muscle tone, irritability) 3. Facial dysmorphology
Microcephaly Microcephaly Microphthalmia (smallness of the eye)
Microphthalmia (smallness of the eye) Thin upper lip Thin upper lip
Slide 70 Pharmacokinetics Rapidly absorbed into blood by stomach
(20%) and small intestine (80%) 2% excreted unchanged in sweat,
breath, & urine Distributed in body fluids (not fat) 1 standard
drink per hour raises BAC by about 0.010.03 g%. 5 minutes to affect
brain Metabolised by liver (95% 99%) alcohol acetaldehyde acetic
acid & H 2 O CO 2 Slide 71 Alcohol: Effects on the brain No
single receptor. Alcohol interacts with and alters function of many
different cellular components. No single receptor. Alcohol
interacts with and alters function of many different cellular
components. Primary targets are GABA, NMDA glutamate, serotonin,
and ATP receptors Primary targets are GABA, NMDA glutamate,
serotonin, and ATP receptors Stimulates dopamine and opioid systems
Stimulates dopamine and opioid systems Effects of chronic
consumption are opposite to acute because of homeostatic
compensation Effects of chronic consumption are opposite to acute
because of homeostatic compensation Slide 72 Alcohol Metabolism
National Institute on Alcohol Abuse and Alcoholism (NIAAA) Slide 73
Effects of alcohol intoxication Slide 74 Types of problems
Intoxication Withdrawal Withdrawal Craving Craving Obsessive
Obsessive Cognitive Conflict Cognitive Conflict Loss of Control
Loss of Control Withdrawal Withdrawal Craving Craving Obsessive
Obsessive Cognitive Conflict Cognitive Conflict Loss of Control
Loss of Control Regular Use Dependence Slide 75 Types of problems:
Clinical samples Intox. Regular Use Dependence Slide 76 Binge
drinking Binge drinking can lead to: increased risk taking
increased risk taking poor judgement / decision making poor
judgement / decision making Misadventure / accidents Misadventure /
accidents increased risky sexual behaviour increased risky sexual
behaviour increased violence increased violence suicide suicide
Slide 77 Harms associated with high-risk alcohol use Hypertension,
CVA Hypertension, CVA Cardiomyopathy Cardiomyopathy Peripheral
neuropathy Peripheral neuropathy Impotence Impotence Cirrhosis and
hepatic or bowel carcinomas Cirrhosis and hepatic or bowel
carcinomas Cancer of lips, mouth, throat, and esophagus Cancer of
lips, mouth, throat, and esophagus Cancer of breast Cancer of
breast Fetal alcohol syndrome Fetal alcohol syndrome Slide 78
Alcohol-related brain injury Cognitive impairment may result from
consumption levels of >70 grams per day Cognitive impairment may
result from consumption levels of >70 grams per day Thiamine
deficiency leads to: Thiamine deficiency leads to: Wernickes
encephalopathy Wernickes encephalopathy Korsakoffs psychosis
Korsakoffs psychosis Frontal lobe syndrome Frontal lobe syndrome
Cerebellar degeneration Cerebellar degeneration Trauma Trauma Slide
79 Interventions and treatment for alcohol-related problems
Screening and assessment individualised interventions Screening and
assessment individualised interventions Brief intervention and harm
reduction strategies Brief intervention and harm reduction
strategies Withdrawal management Withdrawal management Relapse
prevention / goal-setting strategies Relapse prevention /
goal-setting strategies Controlled drinking programs Controlled
drinking programs Residential programs Residential programs
Self-help groups Self-help groups Slide 80 Brief Intervention
Consider the patients: perspective on drinking perspective on
drinking attitudes towards drinking goals attitudes towards
drinking goals significant others significant others short-term
objectives short-term objectivesProvide: information on standard
drinks, risks, and risk levels information on standard drinks,
risks, and risk levels encouragement to identify positive
alternatives to drinking encouragement to identify positive
alternatives to drinking self-help manuals self-help manuals
follow-up session follow-up session Slide 81 Two steps towards
alcohol brief intervention (BI) 1. Screening For example, the
alcohol AUDIT, a 10-item questionnaire For example, the alcohol
AUDIT, a 10-item questionnaire 2. Intervention Information
Information Brief counselling Brief counselling Advice Advice
Referral (if required) Referral (if required) Slide 82 AUDIT The
FLAGS approach After administering the AUDIT, useFLAGS: Feedback
results Feedback results Listen to patient concerns Listen to
patient concerns Provide Alcohol education and information Provide
Alcohol education and information Goals of treatment identify and
plan Goals of treatment identify and plan Strategies discussed and
implemented Strategies discussed and implemented Slide 83 Benefits
of cutting down or cutting out: save money save money be less
depressed be less depressed lose weight lose weight less hassles
for family less hassles for family have more energy have more
energy sleep better sleep better better physical shape better
physical shape Harm-minimising strategies Reduce the risk of: liver
disease cancer brain damage high blood pressure accidents injury
legal problems Slide 84 Choosing a treatment option Slide 85
Withdrawal Usually occurs 6 24 hours after last drink: Tremor
Tremor anxiety and agitation anxiety and agitation Sweating
Sweating nausea and vomiting nausea and vomiting Headache Headache
sensory disturbances hallucinations sensory disturbances
hallucinations Severity depends on: pattern, quantity and duration
of use pattern, quantity and duration of use previous withdrawal
history previous withdrawal history patient expectations patient
expectations physical and psychological wellbeing of the patient
(illness or injury) physical and psychological wellbeing of the
patient (illness or injury) other drug use/dependence other drug
use/dependence the setting in which withdrawal takes place the
setting in which withdrawal takes place Slide 86 Progress of
Alcohol Withdrawal from Time of Last Drink (Source: deCrespigny
& Cusack (2003) Adapted from NSW Health Detoxification Clinical
Practice Guidelines (20002003)) Slide 87 Treatment of alcohol
withdrawal symptoms Diazepam Diazepam Thiamine & multivitamins
Thiamine & multivitamins Antiemetic Antiemetic Analgesia (e.g.,
paracetamol) Analgesia (e.g., paracetamol) Antidiarrhoeal
Antidiarrhoeal Medications for Symptomatic Treatment Slide 88
Post-withdrawal management Treatment options: retain in treatment,
ongoing management retain in treatment, ongoing management seek
referral seek referralConsiderations: patients wants (abstinence or
reduced consumption, remaining your patient) patients wants
(abstinence or reduced consumption, remaining your patient)
severity of problems severity of problemsPharmacotherapies:
acamprosate acamprosate naltrexone naltrexone disulfiram disulfiram
Slide 89 Naltrexone and Acamprosate Effective. Effective. Work well
with variety of supportive treatments, e.g., brief intervention,
CBT, supportive group therapy. Work well with variety of supportive
treatments, e.g., brief intervention, CBT, supportive group
therapy. Start following alcohol withdrawal. Proven efficacy where
goal is abstinence, uncertain with goal of moderation. Start
following alcohol withdrawal. Proven efficacy where goal is
abstinence, uncertain with goal of moderation. No contraindication
while person is still drinking, although efficacy uncertain. No
contraindication while person is still drinking, although efficacy
uncertain. Generally safe and well tolerated. Generally safe and
well tolerated. Slide 90 Clinical guidelines Naltrexone 50 mg
daily: indicated especially where strong craving for alcohol after
a priming dose indicated especially where strong craving for
alcohol after a priming dose likelihood of lapse progressing to
relapse likelihood of lapse progressing to relapse LFTs < x3
above normal LFTs < x3 above normal side effects: nausea in the
first few days side effects: nausea in the first few days
Acamprosate 600 mg (2 tabs) tds: indicated especially when
susceptible to drinking cues or drinking triggered by withdrawal
symptoms indicated especially when susceptible to drinking cues or
drinking triggered by withdrawal symptoms low potential for drug
interactions low potential for drug interactions need normal renal
function need normal renal function side effects: diarrhoea,
headache, nausea, itch side effects: diarrhoea, headache, nausea,
itch Slide 91 Disulfiram Acetaldehyde dehydrogenase inhibitor 200
mg daily Acetaldehyde dehydrogenase inhibitor 200 mg daily
unpleasant reaction with alcohol ingestion (depending on dose)
unpleasant reaction with alcohol ingestion (depending on dose)
Indications: alcohol dependence + goal of abstinence + need for
external aid to abstinence Indications: alcohol dependence + goal
of abstinence + need for external aid to abstinence Controlled
trials: abstinence rate in first 36 months Controlled trials:
abstinence rate in first 36 months Best results with supervised
ingestion & contingency management strategies Best results with
supervised ingestion & contingency management strategies
Caution when using with patients who have significant symptoms of
depression Caution when using with patients who have significant
symptoms of depression Slide 92 Benzodiazepines: the opium of the
massesBenzodiazepines: the opium of the masses (Source: Malcolm
Lader, Neuroscience, 1978) Benzodiazepines Slide 93
Benzodiazepines: History 1950s Invented by Swiss chemists who
identified its sedative effects 1950s60s Chlordiazepoxide (Librium)
marketed as a safer alternative to barbiturates; along with newer
benzodiazepines (BZDs), promoted as having no dependence-inducing
properties! 1970s80sBZDs most commonly prescribed drug class in the
world 1990s on Some decline in the number of prescriptions due to
problems related to dependence and reduced therapeutic value.
Generally safer than barbiturates; problems are with longer term
and polydrug use 1998 8.89 million prescriptions dispensed Slide 94
General medical / psychiatric indications for benzodiazepine use
Anxiolytic chronic / phobic anxiety & panic attacks Anxiolytic
chronic / phobic anxiety & panic attacks Sedative and hypnotic
sleep disturbance & anaesthesia / premedication Sedative and
hypnotic sleep disturbance & anaesthesia / premedication
Anticonvulsant status epilepticus, myoclonic & photic epilepsy
Anticonvulsant status epilepticus, myoclonic & photic epilepsy
Muscle relaxant muscle spasm / spasticity Muscle relaxant muscle
spasm / spasticity Alcohol withdrawal Alcohol withdrawal Slide 95
Exercise: Case study After the recent and unexpected death of her
husband from an MI, Shirley, aged 62, presented for you to check
her cardiac state as she fears a similar fate to her husbands. She
is afraid to go out alone, and she fears going to sleep as she is
scared she will not wake up. She experiences occasional
non-radiating chest pain. She has been taking sleeping tablets for
several years and finds that they are now no longer working. What
would be an appropriate treatment option and plan for Shirley?
Slide 96 Patterns of use BZDs are one of the most prescribed drugs
BZDs are one of the most prescribed drugs 4% of all prescriptions
from general practitioners are for benzodiazepines (BZDs) 4% of all
prescriptions from general practitioners are for benzodiazepines
(BZDs) Predictors for BZD prescription include: Predictors for BZD
prescription include: being female being female being elderly being
elderly being an established patient being an established patient
attending a busy doctor, or a doctor in inner urban area attending
a busy doctor, or a doctor in inner urban area Over 40% of
prescriptions given to people >70 years old Over 40% of
prescriptions given to people >70 years old Night time use tends
to increase with age Night time use tends to increase with age 58%
of current users report daily use for >6 months 58% of current
users report daily use for >6 months Slide 97 BZDs and long-term
use Long-term use is common and associated with: Long-term use is
common and associated with: altered use patterns (from nighttime to
daytime use) altered use patterns (from nighttime to daytime use)
excessive sedation excessive sedation cognitive impairment
cognitive impairment increased risk of accidents increased risk of
accidents adverse sleep effects adverse sleep effects dependence
and withdrawal (even at therapeutic doses) dependence and
withdrawal (even at therapeutic doses) BZDs have an additive effect
with alcohol / other CNS depressants, increasing the risk of harm
BZDs have an additive effect with alcohol / other CNS depressants,
increasing the risk of harm BZDs have limited long-term efficacy
BZDs have limited long-term efficacy Slide 98 BZD and illicit drug
use Illicit BZD use is usually oral, although around 5% are likely
to inject (usually males) Illicit BZD use is usually oral, although
around 5% are likely to inject (usually males) Often 2 nd drug of
choice for illicit drug users, as BZDs assist withdrawal from
opioids, stimulants, and alcohol Often 2 nd drug of choice for
illicit drug users, as BZDs assist withdrawal from opioids,
stimulants, and alcohol Estimated around 70% of people using >50
mg per day are polydrug users, who tend to: Estimated around 70% of
people using >50 mg per day are polydrug users, who tend to: be
younger be younger have higher daily doses and higher lifetime
exposure have higher daily doses and higher lifetime exposure use
in combination with other CNS depressants to increase intoxication
use in combination with other CNS depressants to increase
intoxication prefer fast-acting BZDs (diazepam, flunitrazepam)
prefer fast-acting BZDs (diazepam, flunitrazepam) may convert form
to enable injection may convert form to enable injection Slide 99
Benzodiazepines: Half-life Benzodiazepines Half-life (hrs) 2
[active metabolite] Appr. Equivalent Oral dosages (mg)3 Alprazolam
(Xanax, Xanor, Tafil) 6-120.5 Diazepam(Valium)20-100[36-200]10
Clonazepam (Klonopin, Rivotril) 18-500.5 Slide 100 Pharmacodynamics
Rapidly absorbed orally (slower rate of absorption IM) Rapidly
absorbed orally (slower rate of absorption IM) Lipid soluble -
differences determine rate of passage through blood brain barrier,
i.e., Lipid soluble - differences determine rate of passage through
blood brain barrier, i.e., lipophilic speed of onset lipophilic
speed of onset Duration of action variable Duration of action
variable lipophilic duration of action due to distribution in
adipose tissue lipophilic duration of action due to distribution in
adipose tissue Slide 101 Metabolism Metabolised in the liver mostly
oxidative transformation prior to conjugation with glucuronic acid
for urinary excretion Metabolised in the liver mostly oxidative
transformation prior to conjugation with glucuronic acid for
urinary excretion Elimination half life (drug & active
metabolites) ranges from 8 >60 hours, if short half life &
no active metabolites, it rapidly attains steady state with minimal
accumulation Elimination half life (drug & active metabolites)
ranges from 8 >60 hours, if short half life & no active
metabolites, it rapidly attains steady state with minimal
accumulation Slide 102 Neurotransmission Potentiate
neurotransmission mediated by GABA (main inhibitory
neurotransmitter), therefore neurons are more difficult to excite
Potentiate neurotransmission mediated by GABA (main inhibitory
neurotransmitter), therefore neurons are more difficult to excite
Specific neuronal membrane receptors for BZD closely associated
with synaptic GABA receptors Specific neuronal membrane receptors
for BZD closely associated with synaptic GABA receptors Receptors
distributed through CNS, concentrated in reticular formation &
limbic systems, also peripheral binding sites Receptors distributed
through CNS, concentrated in reticular formation & limbic
systems, also peripheral binding sites Further understanding of the
effects of BZDs on receptor subgroups may lead to the development
of non-sedating anxiolytic BZDs Further understanding of the
effects of BZDs on receptor subgroups may lead to the development
of non-sedating anxiolytic BZDs Slide 103 Effects: Low dose Short
term: Sedation Sedation Anxiety relief Anxiety relief
Anticonvulsant properties Anticonvulsant properties Can usually
attend daily business (though should not drive in first 2 weeks of
treatment) Can usually attend daily business (though should not
drive in first 2 weeks of treatment) Other effects: Drowsiness,
lethargy, fatigue Drowsiness, lethargy, fatigue Impaired
concentration, coordination, memory Impaired concentration,
coordination, memory Reduced ability to think and learn Reduced
ability to think and learn Clumsiness, ataxia Clumsiness, ataxia
Depression Depression Mood swings Mood swings Blurred vision and /
or vertigo Blurred vision and / or vertigo Light-headedness
Light-headedness Nausea, constipation, dry mouth, loss of appetite
Nausea, constipation, dry mouth, loss of appetite Slide 104
Effects: High dose Short term Sedation Sedation Intoxication
Intoxication Drowsiness Drowsiness Other effects Paradoxical
excitement Paradoxical excitement Mood swings Mood swings Hostile
and erratic behaviour Hostile and erratic behaviour Toxicity
Performance deficits Performance deficits Emotional blunting
Emotional blunting Muscle weakness Muscle weakness Sensitivity
Sensitivity Potentiates other drugs Potentiates other drugs
Euphoria, hypomania Euphoria, hypomania Slide 105 Drug + alcohol
interactions CNS depressants, CNS depressants, e.g.,
benzodiazepines Antipsychotics, antidepressants Antipsychotics,
antidepressants Opioid analgesics, antihistamines (some) Opioid
analgesics, antihistamines (some) Hypoglycaemics (chlorpropamide),
metronidazole, cephalosporins (some) Hypoglycaemics
(chlorpropamide), metronidazole, cephalosporins (some) Confusion,
depressed respiration Decreased metabolism, toxicity & CNS
depression CNS depression Facial flushing, headache Slide 106
Overdose Benzodiazepines are the most commonly implicated drug in
overdose cases Benzodiazepines are the most commonly implicated
drug in overdose cases On their own, unlikely to cause death
despite causing respiratory depression On their own, unlikely to
cause death despite causing respiratory depression Serious /
potentially fatal implications when used in combination with other
CNS depressants Serious / potentially fatal implications when used
in combination with other CNS depressants Slide 107 Overdose
response Overdose depresses the conscious state and respiratory
system. Airway management and assisted ventilation is necessary.
Flumazenil a BZD antagonist which reverses BZD overdose, though
contraindicated outside the emergency department a BZD antagonist
which reverses BZD overdose, though contraindicated outside the
emergency department precipitates seizures in: precipitates
seizures in: chronic BZD users chronic BZD users pre-existing
epilepsy pre-existing epilepsy tricyclic antidepressant users
tricyclic antidepressant users concurrent amphetamine or cocaine
users concurrent amphetamine or cocaine users Slide 108 Assessment
Review BZD medication Review BZD medication initial reasons for use
initial reasons for use type of BZD, response to, and patterns of
use type of BZD, response to, and patterns of use side-effects
reported or observed side-effects reported or observed current /
past withdrawal history and symptoms current / past withdrawal
history and symptoms Obtain physical history (concurrent medical
problems) Obtain physical history (concurrent medical problems)
Mental health history (e.g., depression) Mental health history
(e.g., depression) Other drug (and alcohol / prescription drug) use
Other drug (and alcohol / prescription drug) use Discuss options
Discuss options risks of continued and prolonged use risks of
continued and prolonged use withdrawal potential / risks,
management options withdrawal potential / risks, management options
Slide 109 1. Low dose dependence occurs among women and elderly
prescribed low doses over long time periods (up to 40% experience
withdrawal symptoms) 2. High dose dependence occurs among polydrug
users Dependence Two groups of patients are especially likely to
develop dependence. Slide 110 Withdrawal 40% of people on long-term
therapeutic BZD doses will experience withdrawal if abruptly ceased
40% of people on long-term therapeutic BZD doses will experience
withdrawal if abruptly ceased Symptoms occur within 2 short-acting
to 7 day long-acting forms Symptoms occur within 2 short-acting to
7 day long-acting forms BZD withdrawal: BZD withdrawal: is not
life-threatening & usually protracted is not life-threatening
& usually protracted initial symptoms / problems re-emerge on
cessation initial symptoms / problems re-emerge on cessation issues
usually more complicated on cessation issues usually more
complicated on cessation Seizures uncommon (unless high dose use or
abrupt withdrawal, + alcohol use) Seizures uncommon (unless high
dose use or abrupt withdrawal, + alcohol use) Two main groups of
users: Two main groups of users: prescribed (older women)
prescribed (older women) high level, erratic polydrug use high
level, erratic polydrug use Slide 111 Withdrawal severity Severity
of withdrawal is dependent on: pattern and extent of use (duration,
quantity, type (half-life)) pattern and extent of use (duration,
quantity, type (half-life)) withdrawal experience (prior symptoms,
success, complications) withdrawal experience (prior symptoms,
success, complications) coexisting physical / mental health
problems coexisting physical / mental health problems Slide 112 3
Areas of BZD withdrawal Anxiety and anxiety-related symptoms
anxiety, panic attacks, hyperventilation, tremor anxiety, panic
attacks, hyperventilation, tremor sleep disturbance, muscle spasms,
anorexia, weight loss sleep disturbance, muscle spasms, anorexia,
weight loss visual disturbance, sweating visual disturbance,
sweating dysphoria dysphoria Perceptual distortions
hypersensitivity to stimuli hypersensitivity to stimuli abnormal
body sensations abnormal body sensations
depersonalisation/derealisation depersonalisation/derealisation
Major events seizures (grand mal type) seizures (grand mal type)
precipitation of psychosis precipitation of psychosis Slide 113
Withdrawal management Obtain an accurate consumption history Obtain
an accurate consumption history Calculate diazepam equivalent and
substitute. Reduce gradually over 68 weeks (or longer, e.g., 34
months) Calculate diazepam equivalent and substitute. Reduce
gradually over 68 weeks (or longer, e.g., 34 months) Reduce dose by
a fixed rate at weekly intervals (usually 10%20% initially, then
5%10% / week, or slower when dose at 15 mg or less). Reduce dose by
a fixed rate at weekly intervals (usually 10%20% initially, then
5%10% / week, or slower when dose at 15 mg or less). Supervision of
long-term BZD reductions (3-4 months) Supervision of long-term BZD
reductions (3-4 months) Dose at regular times Dose at regular times
Regularly review and titrate dose to match symptoms Regularly
review and titrate dose to match symptoms If symptoms re-emerge,
dose may be plateaued for 12 weeks, or increased before reduction
resumed If symptoms re-emerge, dose may be plateaued for 12 weeks,
or increased before reduction resumed Provide support, not
pharmacological alternatives for conditions such as insomnia and
anxiety. Provide support, not pharmacological alternatives for
conditions such as insomnia and anxiety. Slide 114 Outpatient
withdrawal protocol Consider outpatient withdrawal management:
Consider outpatient withdrawal management: if willing, committed,
compliant, and has adequate social supports if willing, committed,
compliant, and has adequate social supports if taking < 50 mg
diazepam equivalent or therapeutic doses if taking < 50 mg
diazepam equivalent or therapeutic doses if no previous history of
complicated withdrawal if no previous history of complicated
withdrawal if able to attend weekly reviews if able to attend
weekly reviews Develop an individualised withdrawal plan
considering: Develop an individualised withdrawal plan considering:
psychosocial factors psychosocial factors coping skills coping
skills previous attempts previous attempts counselling / referral
needs counselling / referral needs Slide 115 Inpatient withdrawal
protocol Inpatient withdrawal management is necessary if the
patient: is using > 50 mg diazepam equivalent for >14 days is
using > 50 mg diazepam equivalent for >14 days has a history
of alcohol or other drug use or dependence has a history of alcohol
or other drug use or dependence has concurrent medical or
psychiatric problem has concurrent medical or psychiatric problem
has a history of withdrawal seizures has a history of withdrawal
seizures if significant symptoms are predicted if significant
symptoms are predicted is in an unstable social situation is in an
unstable social situation has previous poor compliance / doubtful
motivation has previous poor compliance / doubtful motivation is in
concurrent methadone stabilisation is in concurrent methadone
stabilisation Slide 116 Drug interactions BZDs either potentiate /
increase effects or interfere with metabolism or absorption of :
alcohol alcohol antidepressants and antihistamines antidepressants
and antihistamines disulfiram, cimetidine, erythromycin disulfiram,
cimetidine, erythromycin anticonvulsants anticonvulsants
anticoagulants, oral diabetic agents anticoagulants, oral diabetic
agents cisapride cisapride Slide 117 Exercise: Case study Meg, a
47-year-old woman, always has alcohol on her breath and frequently
falls. She moved into the suburb a few months ago and is well known
at the local liquor shop and hotel. She denied alcohol use until a
recent fracture and hospital admission. Since her discharge, she
has started drinking again, mostly spirits. She presents to you
late one afternoon seeking benzodiazepines. As her doctor, how will
you respond? If her alcohol use continues, how can harm be reduced?
Slide 118 Thank you for your time! End of Workshop 2 Slide 119
Questions?Comments? ? ? ? Slide 120 Workshop 3: Psychostimulants,
Volatile Substances, and Cannabis: Medical Issues and Treatment
Approaches Slide 121 Training objectives At the end of this
training you will: Understand acute and chronic effects of
psychostimulants, volatile substances, and cannabis and the medical
and psychiatric dangers associated with intoxication, overdose,
withdrawal, and interactions with other substances. Understand
acute and chronic effects of psychostimulants, volatile substances,
and cannabis and the medical and psychiatric dangers associated
with intoxication, overdose, withdrawal, and interactions with
other substances. Know treatment protocols to treat intoxication
and overdose Know treatment protocols to treat intoxication and
overdose Know withdrawal approaches and protocols Know withdrawal
approaches and protocols Know about necessary treatments following
detoxification Know about necessary treatments following
detoxification Know proper setting and support services needed to
properly conduct treatments Know proper setting and support
services needed to properly conduct treatments Slide 122 Stimulants
CRACK METHAMPHETAMINE COCAINE Slide 123 Stimulants Description: A
group of synthetic and plant- derived drugs that increase alertness
and arousal by stimulating the central nervous system. Although
MDMA (ecstasy) has some hallucinogenic properties, it is often
classified as a stimulant Medical Uses: Short-term treatment of
obesity, narcolepsy, and hyperactivity in children Method of Use:
Intravenous, intranasal, oral, smoking Slide 124 Types of stimulant
drugs Amphetamine Type Stimulants (ATS) Amphetamine Amphetamine
Dexamphetamine Dexamphetamine Methylphenidate Methylphenidate
Methamphetamine (speed, crystal, ice, yaba, shabu) Methamphetamine
(speed, crystal, ice, yaba, shabu) Slide 125 Types of stimulant
drugs Cocaine Products Cocaine Products Cocaine powder (generally
sniffed, injected, smoked on foil) Cocaine powder (generally
sniffed, injected, smoked on foil) Crack (smoked) Crack (smoked)
Slide 126 Types of stimulant drugs Methyldioxymethamphetamine
(MDMA) (A synthetic drug with psychostimulant and hallucinogenic
properties) Commonly referred to as ecstasy. Sold in tablet form
Commonly referred to as ecstasy. Sold in tablet form Estimated to
be 10 million users worldwide Estimated to be 10 million users
worldwide Slide 127 According to surveys and estimates by WHO and
UNODC, ATS is the most widely used category of illicit drugs in the
world except for cannabis. According to surveys and estimates by
WHO and UNODC, ATS is the most widely used category of illicit
drugs in the world except for cannabis. Worldwide, there an
estimated 26 million or more regular users of amphetamine,
methamphetamine, or ecstasy, as compared to approximately 16
million heroin users and 14 million cocaine users. Worldwide, there
an estimated 26 million or more regular users of amphetamine,
methamphetamine, or ecstasy, as compared to approximately 16
million heroin users and 14 million cocaine users. Methamphetamine
accounts for over 90% of the ATS used worldwide Methamphetamine
accounts for over 90% of the ATS used worldwide Scope of the ATS
problem worldwide Slide 128 Methamphetamine vs. cocaine Cocaine
half-life: 2 hours Cocaine half-life: 2 hours Methamphetamine
half-life: 10 hours Methamphetamine half-life: 10 hours Cocaine
paranoia: 4 - 8 hours following drug cessation Cocaine paranoia: 4
- 8 hours following drug cessation Methamphetamine paranoia: 7-14
days Methamphetamine paranoia: 7-14 days Methamphetamine psychosis
- May require medication / hospitalisation and may not be
reversible Methamphetamine psychosis - May require medication /
hospitalisation and may not be reversible Neurotoxicity: Appears to
be more profound with amphetamine-like substances Neurotoxicity:
Appears to be more profound with amphetamine-like substances Slide
129 Acute stimulant effects Psychological Increased energy
Increased energy Increased clarity Increased clarity Increased
competence Increased competence Heightened feelings of sexuality
Heightened feelings of sexuality Increased sociability Increased
sociability Improved mood Improved mood Powerful rush of euphoria -
freebase and intravenous only Powerful rush of euphoria - freebase
and intravenous only Slide 130 Acute stimulant effects Physical
Increased heart rate Increased heart rate Increased pupil size
Increased pupil size Increased body temperature Increased body
temperature Increased respiration Increased respiration Cardiac
arrhythmias Cardiac arrhythmias Constriction of small blood vessels
Constriction of small blood vessels Decreased appetite Decreased
appetite Decreased need for sleep Decreased need for sleep Slide
131 Chronic stimulant effects Physical Weight loss / anorexia
Weight loss / anorexia Sleep deprivation Sleep deprivation
Respiratory system disease Respiratory system disease
Cardiovascular disease Cardiovascular disease Headaches Headaches
Severe dental disease Severe dental disease Needle marks and
abscesses - intravenous only Needle marks and abscesses -
intravenous only Seizures Seizures Slide 132 Long-term effects of
stimulants Strokes, seizures, and headaches Irritability,
restlessness Depression, anxiety, irritability, anger Memory loss,
confusion, attention problems Insomnia Paranoia, auditory
hallucinations, panic reactions Suicidal ideation Sinus infection
Loss of sense of smell, nosebleeds, chronic runny nose, hoarseness
Dry mouth, burned lips Worn teeth (due to grinding during
intoxication) Problems swallowing Chest pain, cough, respiratory
failure Disturbances in heart rhythm and heart attack
Gastrointestinal complications (abdominal pain and nausea) Loss of
libido Malnourishment, weight loss, anorexia Weakness, fatigue
Tremors Sweating Oily skin, complexion Slide 133 Slide 134 Slide
135 Meth Mouth Meth use leads to severe tooth decay Source: The New
York Times, June 11, 2005 Slide 136 Prenatal meth exposure
Preliminary findings on infants exposed prenatally to
methamphetamine (MA) and nonexposed infants suggest Prenatal
exposure to MA is associated with an increase in SGA (small for
gestational size). Prenatal exposure to MA is associated with an
increase in SGA (small for gestational size). Neurobehavioural
deficits at birth were identified in NNNS (Neonatal Intensive Care
Unit Network Neurobehavioral Scale) neurobehaviour, including dose
response relationships and acoustical analysis of the infants cry.
Neurobehavioural deficits at birth were identified in NNNS
(Neonatal Intensive Care Unit Network Neurobehavioral Scale)
neurobehaviour, including dose response relationships and
acoustical analysis of the infants cry. (Source: Lester et al.,
2005) Slide 137 Chronic stimulant effects Psychological Severe
anxiety Severe anxiety Paranoia Paranoia Psychosis Psychosis
Irritability Irritability Confusion Confusion Desire to isolate
Desire to isolate Memory impairment Memory impairment Inability to
concentrate Inability to concentrate Loss of control Loss of
control Aggressiveness Aggressiveness Slide 138 Methamphetamine:
Psychiatric consequences Paranoid reactions Paranoid reactions
Protracted memory impairment Protracted memory impairment
Depressive/dysthymic reactions Depressive/dysthymic reactions
Hallucinations Hallucinations Psychotic reactions Psychotic
reactions Panic disorders Panic disorders Rapid addiction Rapid
addiction Slide 139 Stimulant withdrawal symptoms Depression
Depression Difficulty concentrating Difficulty concentrating
Increased need for sleep / insomnia Increased need for sleep /
insomnia Memory dysfunction Memory dysfunction Anxiety Anxiety
Decreased sex drive Decreased sex drive Low energy Low energy
Irritability Irritability Headache Headache Craving Craving Slide
140 Synaptic activity Slide 141 Meth / Amphetamine Effects: Onset
and Duration 1 min3min60 min6 hours 1 min3min20 min30 min Effect
Intensity Amphetamine Cocaine Injection Intranasal Swallowed
Duration of effect Slide 142 MildModerateToxic Sleeplessness
Reduced appetite Dry mouth Crash Suspicion Headache Teeth grinding
Anxiety Extreme agitation Incoherence Increased temperature
Dehydration Thought disorder Violent aggression Stroke Heart attack
Feel good Alert Energy Confidence Feel great Increased libido
Increased stamina No need for sleep Amphetamine Effects Slide 143
Typical Pattern of Use (Pead, et al., 1996, p. 37) -7 02515202530+
Low High Symptom Severity UsingStopping Run Intoxication Thought
disorder Agitation Insomnia Suspicion Increased energy Feel good
Exhaustion Depression Oversleeping Overeating No craving Anhedonia
Lack energy Anxiety Sleepless High craving Flat mood Emotionally
fragile Episodic craving to cues Days Crash Run Withdrawal Slide
144 Assessment points Occupation Occupation Age Age Social
activities Social activities Alcohol and drug (AOD) use history
Alcohol and drug (AOD) use history patterns of use, drug type,
route, other drug use patterns of use, drug type, route, other drug
use Physical health (e.g., stability of weight) Physical health
(e.g., stability of weight) Mental health (emotional lability,
psychosis/paranoia) Mental health (emotional lability,
psychosis/paranoia) Current level of intoxication / evidence of
withdrawal Current level of intoxication / evidence of withdrawal
Laboratory investigations Laboratory investigations Slide 145
Management of toxic reactions Priorities are: maintain airway,
circulation, breathing maintain airway, circulation, breathing
control elevated body temperature (hydration, cold water, ice)
control elevated body temperature (hydration, cold water, ice)
control seizures (IV diazepam) control seizures (IV diazepam)
manage psychotic symptoms (antipsychotics) manage psychotic
symptoms (antipsychotics) reassurance, support, comfort, minimal
stimulation reassurance, support, comfort, minimal stimulation
Treatment depends on patients condition on presentation. Slide 146
Activity: Case study Rory, a 24-year-old student, presents with
persistent headache, lethargy, and unexplained weight loss. He is
burning the candle at both ends, working in a bar and studying, and
states that life is pretty hectic at present. Speed helps him get
things done. Describe a brief intervention for Rory. Slide 147
Psychostimulant Withdrawal From Pead et al. (1996, p. 84) Slide 148
Withdrawal treatment Immediate withdrawal treatment setting
(outpatient or inpatient) setting (outpatient or inpatient)
supportive environment, information, and reassurance supportive
environment, information, and reassurance provide ongoing
monitoring provide ongoing monitoring plan long-term management
strategies plan long-term management strategies Planning for
prolonged withdrawal anticipate it will be prolonged (i.e.,
affecting sleep, mood, cravings) anticipate it will be prolonged
(i.e., affecting sleep, mood, cravings) plan for lapse and relapse
plan for lapse and relapse Slide 149 Pharmacotherapies for
psychostimulant withdrawal Aim to decrease discomfort Aim to
decrease discomfort Benzodiazepines Benzodiazepines assist sleep or
reduce anxiety and agitation assist sleep or reduce anxiety and
agitation avoid long-term prescribing avoid long-term prescribing
Antipsychotics and Antidepressants Antipsychotics and
Antidepressants available research shows limited efficacy available
research shows limited efficacy Slide 150 Promising
pharmacotherapies? Newton, T. et al (Biological Psychiatry, Dec,
2005) Bupropion reduces craving and reinforcing effects of
methamphetamine in a laboratory self- administration study. Newton,
T. et al (Biological Psychiatry, Dec, 2005) Bupropion reduces
craving and reinforcing effects of methamphetamine in a laboratory
self- administration study. Elkashef, A. et al
(Neuropsychopharmcology, 2007) Bupropion reduces meth use in an
outpatient trial, with particularly strong effect with less severe
users. Elkashef, A. et al (Neuropsychopharmcology, 2007) Bupropion
reduces meth use in an outpatient trial, with particularly strong
effect with less severe users. Tiihonen, J. et al (recently
completed; reported at the ACNP methamphetamine satelite meeting in
Kona, Hawaii) Methylphenidate SR (sustained release) has shown
promise in a recent Finnish study with very heavy amphetamine
injectors. Tiihonen, J. et al (recently completed; reported at the
ACNP methamphetamine satelite meeting in Kona, Hawaii)
Methylphenidate SR (sustained release) has shown promise in a
recent Finnish study with very heavy amphetamine injectors. Slide
151 Low threshold treatment services for MSM methamphetamine users
Street outreach and field workers in clubs and bath houses Street
outreach and field workers in clubs and bath houses Needle exchange
Needle exchange Drop-in centres for food, medical services Drop-in
centres for food, medical services Housing for homeless
methamphetamine users Housing for homeless methamphetamine users
HIV risk reduction groups employing peer and professional
counselling HIV risk reduction groups employing peer and
professional counselling No empirical evidence at this point No
empirical evidence at this point Slide 152 Activity: Case study
Kylie, a 33-year-old lawyer, recently discovered she was pregnant.
She has an active work and social life, and consequently, tends to
eat poorly. The pregnancy was unplanned. She is concerned about the
health of her baby and her lifestyle that precludes regular eating
habits. How would you incorporate an AOD history into your
consultation? What triggers may lead you to suspect psychostimulant
use? Slide 153 Cocaine Alkaloid from plant leaf of Erythroxylon
coca Alkaloid from plant leaf of Erythroxylon coca Known as coke,
charlie, snow, okey doke Known as coke, charlie, snow, okey doke
Sold in lines Sold in lines Central nervous system stimulant with
local anaesthetic actions Central nervous system stimulant with
local anaesthetic actions Also stimulates the sympathetic nervous
system Also stimulates the sympathetic nervous system Blocks
reuptake of dopamine, noradrenaline, and serotonin Blocks reuptake
of dopamine, noradrenaline, and serotonin CocaineCrack Crack in
vials Slide 154 Cocaine: Metabolism Rapid onset of action (28
minutes respectively) Rapid onset of action (28 minutes
respectively) Peak blood levels occur in 530 minutes Peak blood
levels occur in 530 minutes Action is brief: Action is brief:
half-life of 1530 minutes if injected half-life of 1530 minutes if
injected half-life of up to 30 minutes if snorted half-life of up
to 30 minutes if snorted Metabolised by liver, 1%2% excreted
unchanged in urine Metabolised by liver, 1%2% excreted unchanged in
urine Inactive metabolites can be detected in: Inactive metabolites
can be detected in: blood or urine for 2436 hours after use blood
or urine for 2436 hours after use hair for weeks to months after
use hair for weeks to months after use Slide 155 Cocaine: Acute and
chronic effects Very similar to those associated with
methamphetamine. Since the half-life of cocaine is much shorter, in
comparison to methamphetamine there is: Somewhat less severe
neurotoxicity Somewhat less severe neurotoxicity Somewhat lower
frequency of drug- induced psychosis Somewhat lower frequency of
drug- induced psychosis Somewhat shorter protracted withdrawal
symptoms Somewhat shorter protracted withdrawal symptoms Slide 156
Cocaine: Symptoms of withdrawal Dysphoria (rather than depression),
which may persist (up to 10 weeks). Plus at least two of: Dysphoria
(rather than depression), which may persist (up to 10 weeks). Plus
at least two of: fatigue fatigue insomnia / hypersomnia insomnia /
hypersomnia psychomotor agitation psychomotor agitation craving
craving increased appetite increased appetite vivid unpleasant
dreams vivid unpleasant dreams Withdrawal tends to peak 24 days
following cessation of use. Withdrawal tends to peak 24 days
following cessation of use. Slide 157 Cocaine pharmacotherapy
Disulfiram has been shown to reduce cocaine use significantly in
non-alcohol using cocaine- dependent individuals. However, further
research is needed. Disulfiram has been shown to reduce cocaine use
significantly in non-alcohol using cocaine- dependent individuals.
However, further research is needed. There is substantial use of
other medications for treating short- and long-term effects of
cocaine use. However, controlled research shows no evidence to
support use of these medications. There is substantial use of other
medications for treating short- and long-term effects of cocaine
use. However, controlled research shows no evidence to support use
of these medications. Slide 158 Cocaine: Withdrawal management
Non-stimulating / non-threatening environment Non-stimulating /
non-threatening environment Possible suicide precautions Possible
suicide precautions To date, no effective pharmacotherapies for
withdrawal management To date, no effective pharmacotherapies for
withdrawal management Prescribed medications: Prescribed
medications: Short-term use of benzodiazepines (anxiety, agitation,
promote sleep) Short-term use of benzodiazepines (anxiety,
agitation, promote sleep) Slide 159 Psychostimulant interventions
Be non-judgemental, do not insist on abstinence Be non-judgemental,
do not insist on abstinence Engage and retain patient in treatment
Engage and retain patient in treatment Understand patients
treatment goals Understand patients treatment goals Tailor
intervention to suit patient, including level and intensity of
referrals Tailor intervention to suit patient, including level and
intensity of referrals Offer flexible service delivery, consistent
with a patients changing goals and needs Offer flexible service
delivery, consistent with a patients changing goals and needs
Provide psychosocial support Provide psychosocial support Address
concurrent mental health needs, e.g., anxiety, bipolar, or
attention deficit disorders are common with cocaine use. Address
concurrent mental health needs, e.g., anxiety, bipolar, or
attention deficit disorders are common with cocaine use. Slide 160
Treatments for stimulant-use disorders with empirical support
Cognitive-Behavioral Therapy (CBT) Cognitive-Behavioral Therapy
(CBT) Community Reinforcement Approach Community Reinforcement
Approach Contingency Management Contingency Management 12-Step
Facilitation 12-Step Facilitation Brief Cognitive Behavioral
Therapy Brief Cognitive Behavioral Therapy Matrix Model Matrix
Model All have demonstrated efficacy for the treatment of cocaine
and / or methamphetamine dependence. Slide 161 Volatile Substances
CRACK Slide 162 Volatile substances Commonly referred to as
inhalants, solvents, solvent based products Commonly referred to as
inhalants, solvents, solvent based products Common terms include
chroming, huffing, sniffing, bagging Common terms include chroming,
huffing, sniffing, bagging Comprise a group of chemical compounds
that change from a liquid or semi-solid to gaseous state when
exposed to air Comprise a group of chemical compounds that change
from a liquid or semi-solid to gaseous state when exposed to air
Inhalation of the vapour through the mouth or nose produces a
psychoactive effect (intoxication and euphoria). Inhalation of the
vapour through the mouth or nose produces a psychoactive effect
(intoxication and euphoria). Slide 163 What substances are used?
Inhalants are found in hundreds of products at supermarkets,
newsagencies, hardware stores, and industrial sites Inhalants are
found in hundreds of products at supermarkets, newsagencies,
hardware stores, and industrial sites 4 categories of inhalants: 4
categories of inhalants: Solvents Solvents Aerosols Aerosols Gases
Gases Nitrites Nitrites Slide 164 Pharmacology High lipid
solubility promotes rapid absorption from the lungs High lipid
solubility promotes rapid absorption from the lungs Acute
intoxication occurs after 35 minutes (1015 breaths are sufficient)
Acute intoxication occurs after 35 minutes (1015 breaths are
sufficient) Peak plasma concentration reached in 1530 minutes Peak
plasma concentration reached in 1530 minutes Half-life varies from
hours to days Half-life varies from hours to days Metabolised in
kidneys and liver Metabolised in kidneys and liver Accumulate in
lipid rich organs (i.e., liver, brain) Accumulate in lipid rich
organs (i.e., liver, brain) Crosses placental barrier Crosses
placental barrier Slide 165 Highest prevalence among 14- to
17-year-olds Slide 166 Appeal of volatile substances Inexpensive
Inexpensive Readily available despite legislation precluding sale
to minors Readily available despite legislation precluding sale to
minors Can be packaged in small, discrete containers Can be
packaged in small, discrete containers Create both rapid
intoxication and rapid resolution of intoxication (can use and
still return home sober) Create both rapid intoxication and rapid
resolution of intoxication (can use and still return home sober)
Slide 167 Who uses inhalants? Lack of good epidemiological data,
however data from Australia indicates: highest prevalence among 14-
to 17-year-olds (c.f., older adults) highest prevalence among 14-
to 17-year-olds (c.f., older adults) a small percentage try, but
most cease use after a few attempts a small percentage try, but
most cease use after a few attempts primarily a short-term,
experimental activity by young males (however, female use is
increasing) primarily a short-term, experimental activity by young
males (however, female use is increasing) recreational users tend
to combine solvents and cannabis with ecstasy, speed, or LSD
recreational users tend to combine solvents and cannabis with
ecstasy, speed, or LSD not restricted to Indigenous communities,
but Indigenous youth (compared with non-Indigenous) tend to: not
restricted to Indigenous communities, but Indigenous youth
(compared with non-Indigenous) tend to: show greater habitual use
show greater habitual use use more frequently use more frequently
use over a longer period use over a longer period use of solvents
is of international concern use of solvents is of international
concern Slide 168 Why do youth use volatile substances? Because its
fun and exciting Because its fun and exciting I like the way it
makes me feel I feel drunk I like the way it makes me feel I feel
drunk It takes away my bad feelings It takes away my bad feelings I
wanted to be part of the gang I wanted to be part of the gang My
brothers were doing it so I wanted to try it My brothers were doing
it so I wanted to try it Because I want to do something my parents
dont like Because I want to do something my parents dont like
Because its easy to get and Im not allowed to get alcohol Because
its easy to get and Im not allowed to get alcohol ADAC (2000, p. 8)
Slide 169 Patterns and methods of use 3 major patterns of use:
experimental / occasional experimental / occasional social social
long-term dependent / chronic long-term dependent / chronic Methods
of use: sniffing sniffing huffing huffing bagging bagging Slide 170
Cues for detecting recent use Red, watery eyes Red, watery eyes
Sneezing & coughing (URTI-like symptoms) Sneezing &
coughing (URTI-like symptoms) Chemical smell or odour on breath
Chemical smell or odour on breath Glue, solvent, or paint stains on
clothing, fingers, nose, or mouth Glue, solvent, or paint stains on
clothing, fingers, nose, or mouth Apparent intoxication / altered
behaviour / risk taking Apparent intoxication / altered behaviour /
risk taking Incoherence, confusion Incoherence, confusion Poor
coordination Poor coordination Excessive sweating Excessive
sweating Unusual spots, marks, rashes and sores around nose and
mouth Unusual spots, marks, rashes and sores around nose and mouth
Excessive nasal secretions, constantly sniffing Excessive nasal
secretions, constantly sniffing Slide 171 Volatile effects short
term Desired effects Euphoria Euphoria Excitation Excitation
Exhilaration Exhilaration Sense of invulnerability Sense of
invulnerability Disinhibition Disinhibition Negative acute/ short-
term effects Drowsiness Drowsiness Flu-like symptoms Flu-like
symptoms Nausea and vomiting Nausea and vomiting Headaches
Headaches Diarrhoea, abdominal pain Diarrhoea, abdominal pain
Unpleasant breath Unpleasant breath Nosebleeds and sores Nosebleeds
and sores Reckless behaviour Reckless behaviour Slide 172 Volatile
effects high doses Effects at high doses Slurred speech Slurred
speech Poor coordination Poor coordination Disorientation,
confusion Disorientation, confusion Tremor Tremor Headaches
Headaches Delusions Delusions Visual distortions or hallucinations
Visual distortions or hallucinations Unpredictable behaviour, then:
Unpredictable behaviour, then: ataxia ataxia stupor stupor final
stages (seizures, coma cardiopulmonary arrest, death) final stages
(seizures, coma cardiopulmonary arrest, death) Slide 173 Volatiles
- overdoses High Doses put user at risk for: Convulsions, seizures,
coma Convulsions, seizures, coma Respiratory depression Respiratory
depression Cardiac arrhythmias Cardiac arrhythmias Injury or death
can occur from: Risk-taking behavior (drowning, falls, etc.)
Risk-taking behavior (drowning, falls, etc.) Suffocation
Suffocation Aspiration of vomit Aspiration of vomit Burns,
explosions Burns, explosions Poisoning, organ failure (chronic use)
Poisoning, organ failure (chronic use) Laryngeal spasm (Butane),
respiratory arrest Laryngeal spasm (Butane), respiratory arrest
Lead poisoning (gasoline / petrol) Lead poisoning (gasoline /
petrol) Slide 174 Tolerance and dependence Tolerance develops
rapidly with regular use Tolerance develops rapidly with regular
use Psychological and physical dependence, while rare, may also
occur Psychological and physical dependence, while rare, may also
occur Slide 175 Withdrawal Onset and duration Onset and duration
not classified in DSM IV but features of possible withdrawal
syndrome may commence 24-48 hours after cessation of use not
classified in DSM IV but features of possible withdrawal syndrome
may commence 24-48 hours after cessation of use Withdrawal Symptoms
Withdrawal Symptoms sleep disturbances sleep disturbances tremor
tremor irritability and depression irritability and depression
nausea nausea diaphoresis diaphoresis fleeting illusions fleeting
illusions Treatment Treatment symptomatic symptomatic Slide 176
Problems with long-term use Patients may present with a variety of
symptoms as a consequence of long-term use, including: chronic
headache chronic headache sinusitis, nosebleeds, increased nasal
secretions sinusitis, nosebleeds, increased nasal secretions
diminished cognitive function diminished cognitive function ataxia
ataxia chronic coughing chronic coughing chest pain or angina chest
pain or angina tinnitus tinnitus extreme tiredness, weakness,
dizziness extreme tiredness, weakness, dizziness depression /
anxiety depression / anxiety shortness of breath shortness of
breath indigestion indigestion stomach ulcers stomach ulcers Slide
177 Complications from long-term use CNS complications acute
encephalopathy acute encephalopathy chronic neurological deficits
chronic neurological deficits memory, thinking memory, thinking
hearing loss, and loss of sense of smell hearing loss, and loss of
sense of smell nystagmus nystagmus motor impairment, especially
secondary to lead poisoning motor impairment, especially secondary
to lead poisoning peripheral nerve damage peripheral nerve damage
Other systems Other systems Renal nephrolithiasis, glomerulopathies
Renal nephrolithiasis, glomerulopathies Hepatic reversible
hepatotoxicity Hepatic reversible hepatotoxicity Pulmonary e.g.,
pulmonary hypertension, acute respiratory distress Pulmonary e.g.,
pulmonary hypertension, acute respiratory distress Cardiovascular
e.g., VF, arrhythmias, acute cardiomyopathy Cardiovascular e.g.,
VF, arrhythmias, acute cardiomyopathy Haematological e.g., blood
dyscrasias Haematological e.g., blood dyscrasias Slide 178 Impact
Use of volatile substances (as with use of other psychoactive
drugs) impacts not only personal health but also: families families
workplace safety workplace safety community (e.g., anti-social
behaviour) community (e.g., anti-social behaviour) Slide 179
Responding to intoxication Ensure fresh air Ensure fresh air Be
calm, and calming Be calm, and calming Dont chase, argue, use force
Dont chase, argue, use force Persuade to cease sniffing (if able to
understand) Persuade to cease sniffing (if able to understand) Take
person to a safe environment Take person to a safe environment Dont
attempt to counsel while intoxicated Dont attempt to counsel while
intoxicated Follow-up with parents Follow-up with parents If drowsy
or heavily intoxicated If drowsy or heavily intoxicated consider
the best environment for the individual and monitor physical and
mental health consider the best environment for the individual and
monitor physical and mental health Slide 180 Interventions Brief
intervention Brief intervention Harm reduction Harm reduction
Counselling Counselling Group counselling Group counselling Family
support and counselling Family support and counselling Be involved
in developing community responses (e.g., Drug Action Teams) Be
involved in developing community responses (e.g., Drug Action
Teams) Avoid lectures to school / youth groups evidence suggests it
may increase curiosity and level of use. Slide 181 Cannabanoids
Hashish Marijuana Slide 182 Cannabis The most widely used illicit
drug The most widely used illicit drug The drug most likely to be
seen in general medical practise The drug most likely to be seen in
general medical practise Generally an experimental or recreational
drug, but the most common illicit drug of dependence Generally an
experimental or recreational drug, but the most common illicit drug
of dependence Use is common among polydrug users Use is common
among polydrug users 70% of all drug-related offences relate to
cannabis 70% of all drug-related offences relate to cannabis THC or
delta9tetrahydrocannabinol is the active ingredient of cannabis
Slide 183 Case study Mark is a 23-year-old unemployed labourer who
presents ostensibly with fatigue. On examination, some psychotic
symptoms are apparent. Upon questioning, he says he has been
smoking 30 cones of cannabis a day. He is restless, with
significant mood swings, racing thoughts and paranoia but no real
features of lasting psychosis. Is his presentation consistent with
his drug use? How long are his symptoms likely to last? What advice
might you give him regarding future use? Slide 184 Cannabis: Forms
DEFG A BC Slide 185 Cannabis: Properties Frequently, but
erroneously, classified as a narcotic, sedative, or hallucinogen.
Sits alone within a unique class. Frequently, but erroneously,
classified as a narcotic, sedative, or hallucinogen. Sits alone
within a unique class. Degree of effects determined by the THC
concentration of specific cannabis material used. Degree of effects
determined by the THC concentration of specific cannabis material
used. Major active constituent is THC Major active constituent is
THC(delta-9-tetrahydrocannabinol). rapidly absorbed and metabolised
when smoked, less so when ingested (13 hours for psychoactive
effects). rapidly absorbed and metabolised when smoked, less so
when ingested (13 hours for psychoactive effects). Attaches to
specific cannabinoid receptors (endogenous brain molecule
anandamide). Attaches to specific cannabinoid receptors (endogenous
brain molecule anandamide). Slide 186 Cannabis: Brain receptors Two
types of cannabinoid receptors Two types of cannabinoid receptors
CB 1 & CB 2 CB 1 receptors in brain (cortex, hippocampus, basal
ganglia, amygdala) and peripheral tissues (testes, endothelial
cells) CB 1 receptors in brain (cortex, hippocampus, basal ganglia,
amygdala) and peripheral tissues (testes, endothelial cells) CB 2
receptors associated with the immune system CB 2 receptors
associated with the immune system Most cannabis effects are via THC
acting on CB 1 receptors, which facilitate activity in mesolimbic
dopamine neurones Most cannabis effects are via THC acting on CB 1
receptors, which facilitate activity in mesolimbic dopamine
neurones Slide 187 Cannabis: Forms & routes Forms include:
dried flowers/leaves / buds (marijuana/ganja) dried flowers/leaves
/ buds (marijuana/ganja) 1% 24% THC (depending on genetic and
environmental factors)1% 24% THC (depending on genetic and
environmental factors) extracted dried resin, sometimes mixed with
dried flowers and pressed into a cube (hashish) extracted dried
resin, sometimes mixed with dried flowers and pressed into a cube
(hashish) around 10% 20% THCaround 10% 20% THC extracted oil using
an organic solvent (hashish oil) extracted oil using an organic
solvent (hashish oil) 15% 30% THC15% 30% THC Route of
administration can affect dose: smoked (joint, pipe, bong, bucket
bong, dose ) smoked (joint, pipe, bong, bucket bong, dose ) 50%
absorbed, peak concentration 10 30 mins, lasts 2 4 hours50%
absorbed, peak concentration 10 30 mins, lasts 2 4 hours ingested
(cake, biscuits) ingested (cake, biscuits) 3% 6% absorbed, peak
concentration 2 3 hours, lasts up to 8 hours3% 6% absorbed, peak
concentration 2 3 hours, lasts up to 8 hours Slide 188 Cannabis:
Time to Peak Effect (Smoked) Slide 189 Cannabis: Acute effects
Analgesia Analgesia Euphoria, altered concentration, relaxation,
sense of calm or wellbeing, disinhibition, confusion Euphoria,
altered concentration, relaxation, sense of calm or wellbeing,
disinhibition, confusion Increased appetite, thirst Increased
appetite, thirst Heightened visual, auditory and olfactory
perceptions, inability to appropriately interpret surroundings
Heightened visual, auditory and olfactory perceptions, inability to
appropriately interpret surroundings Reduced intra-ocular pressure
(used for glaucoma treatment) Reduced intra-ocular pressure (used
for glaucoma treatment) Nausea, headaches Nausea, headaches With
consistent use, URTIs With consistent use, URTIs Problems
associated with intoxication Problems associated with intoxication
Cannabis overdose does not result in death. Slide 190 Courtesy of
Dr. John Sherman, St. Kilda Medical Centre Cannabis Slide 191 Short
term, high-dose effects Cannabis also affects: Short-term memory
Short-term memory ability to learn and retain new information
ability to learn and retain new information task performance task
performance balance, stability, mental dexterity balance,
stability, mental dexterity the cardiovascular and respiratory
systems the cardiovascular and respiratory systems Short-term,
high-dose use may result in: synaesthesia synaesthesia pseudo- or
true hallucinations pseudo- or true hallucinations delusions,
feelings of depersonalisation delusions, feelings of
depersonalisation paranoia, agitation, panicky feelings, psychosis
paranoia, agitation, panicky feelings, psychosis Slide 192
Long-term effects CNS CNS Respiratory system Respiratory system
Cardiovascular system Cardiovascular system Immune system Immune
system Endocrine and reproductive systems Endocrine and
reproductive systems Adverse social outcomes Adverse social
outcomes Mental health problems Mental health problems Cognitive
impairment Cognitive impairment Dependence Dependence Slide 193
Cannabis and psychosis THC may exacerbate symptoms of schizophrenia
through increase in dopamine release THC may exacerbate symptoms of
schizophrenia through increase in dopamine release THC likely
precipitates schizophrenia in those vulnerable, i.e., those with a
personal or family history of schizophrenia THC likely precipitates
schizophrenia in those vulnerable, i.e., those with a personal or
family history of schizophrenia Some reports of onset of cannabis-
associated schizophrenia in individuals without family risk factors
Some reports of onset of cannabis- associated schizophrenia in
individuals without family risk factors Slide 194 Cannabis
dependence The cannabis dependence syndrome, while now clearly
described, is perceived as less pronounced than for other drugs
(i.e., opioids, alcohol) The cannabis dependence syndrome, while
now clearly described, is perceived as less pronounced than for
other drugs (i.e., opioids, alcohol) Not yet listed in DSM IV Not
yet listed in DSM IV Variation in frequency, duration of use and
dose result in difficulty predicting rapidity, development, and
duration of withdrawal Variation in frequency, duration of use and
dose result in difficulty predicting rapidity, development, and
duration of withdrawal Slide 195 Withdrawal symptoms Anxiety,
restlessness, irritability, agitation Anxiety, restlessness,
irritability, agitation Racing thoughts Racing thoughts Mood swings
and increased aggression Mood swings and increased aggression
Feelings of unreality Feelings of unreality Fear, sometimes
paranoia Fear, sometimes paranoia Anorexia, stomach pain Anorexia,
stomach pain Weight loss Weight loss Increased body temperature
Increased body temperature Nausea and salivation Nausea and
salivation Drowsiness, through disturbed sleep, and an increase in
vivid dreams Drowsiness, through disturbed sleep, and an increase
in vivid dreams Slide 196 Assessment Assessment should focus on:
drug type, history, route, pattern of use, expenditure drug type,
history, route, pattern of use, expenditure tolerance, dependence,
potential for withdrawal tolerance, dependence, potential for
withdrawal history or evidence of psychiatric sequelae history or
evidence of psychiatric sequelae health complications of cannabis
use health complications of cannabis use psychosocial context of
use (time spent using, obtaining drug, social impact, etc.)
psychosocial context of use (time spent using, obtaining drug,
social impact, etc.) previous attempts to cut down or quit previous
attempts to cut down or quit Assessment tools: SDS SDS ASSIST
ASSIST Slide 197 Treatment approaches (1) Brief Advice Provide
information on the harms associated with: Provide information on
the harms associated with: intoxication intoxication long-term,
regular use of cannabis long-term, regular use of cannabis Provide
advice on reducing or ceasing use: Provide advice on reducing or
ceasing use: Delay, Distract, Avoid, Escape, and dealing with
Lapses Delay, Distract, Avoid, Escape, and dealing with Lapses
Adopt brief motivational and cognitive-behavioural techniques to
manage withdrawal and craving Adopt brief motivational and
cognitive-behavioural techniques to manage withdrawal and craving
Other strategies may include: Other strategies may include:
exercise, stress management, relaxation, hobbies, diet, friends.
exercise, stress management, relaxation, hobbies, diet, friends.
Early intervention may be more effective than education. Slide 198
Treatment approaches (2) Treatment approaches (2) No specific
pharmacotherapies are available yet for managing cannabis
withdrawal or relapse. Slide 199 Treatment approaches (3) Treatment
approaches (3) Relapse prevention can be achieved through: Relapse
prevention can be achieved through: supportive treatment supportive
treatment regular follow-up regular follow-up encouraging patient
to follow-up treatment with counselling or support groups
encouraging patient to follow-up treatment with counselling or
support groups use of self-help tools and techniques use of
self-help tools and techniques Harm reduction can be promoted by:
Harm reduction can be promoted by: assisting patients to identify
harms and possible solutions assisting patients to identify harms
and possible solutions discussing risks associated with driving or
work discussing risks associated with driving or work discussing
possible psychosis with those predisposed to such discussing
possible psychosis with those predisposed to such Slide 200
Withdrawal management No specific pharmacotherapies for managing
cannabis withdrawal or relapse No specific pharmacotherapies for
managing cannabis withdrawal or relapse Effectively managed as an
outpatient, however severe dependence may require specialised
assistance Effectively managed as an outpatient, however severe
dependence may require specialised assistance engage in brief
interventions, including relapse prevention and problem solving
skills engage in brief interventions, including relapse prevention
and problem solving skills consider shared care with psychologists
and / or experienced AOD workers consider shared care with
psychologists and / or experienced AOD workers Slide 201
Pharmacology for withdrawal Medications may be useful for a limited
time: sedative / hypnotics sedative / hypnotics e.g., diazepam 5 10
mg qid prn, temazepam, 10 20 mg nocte for a few days antipsychotics
(for severe agitation or psychosis) antipsychotics (for severe
agitation or psychosis) e.g., haloperidol or novel agents Slide 202
Questions?Comments? ? ? ? Slide 203 Post-assessment Please respond
to the post-assessment questions in your workbook. (Your responses
are strictly confidential.) 10 Min. Slide 204 Thank you for your
time! End of Workshop 3 END OF MODULE 1
